whistleblower submission form form c · whistleblower submission form including a whistleblower...

INDIVIDUAL #1

NAME

ADDRESS

Who is involved? What happened? Supportingdocuments

About thewhistleblower(s)

Counselcertification

Whistleblower Submission Form

For a lawyerrepresenting

whistleblower(s)

Complete this form IF you are a lawyerrepresenting a whistleblower(or a group of whistleblowers)who wish to be anonymous.

If you are a individual whistleblower, please complete Form A instead.If you are a group of whistleblowers acting jointly, please complete

Form B instead.

FORM C

1

1

2 3 4 5

WHO IS INVOLVED IN THE MISCONDUCT?

Who are the individuals involved in the misconduct?

PART

A

First Last

Street

Country

City

Phone number

Job position/Title

Province/State

Email

INDIVIDUAL #2

NAME

ADDRESS

(List the required information for any additional individuals on Attachment 1 at the end of this form.)

First Last

Street

Country

City

Phone number

Job position/Title

Province/State

Email

1.

Your client, the whistleblower, must have provided you with a completed and signed Whistleblower Submission Form including a Whistleblower Certification, the original of which you must retain in your records.

ENTITY #1

NAME

ADDRESS




1 2 3 4 5

Who are the entities involved in the misconduct? B

Street

Country

City

Phone number

Province/State

Website

YES NO I DON’T KNOW

If YES, identify which entities the individual was or is an employee, officer or director of, at the time of the misconduct:

At the time of the misconduct, were, or are, any of the individuals in A) abovean employee, officer or director (a member of the board of directors) at any ofthe entities in B) above?

Individual #1 Entity #1

Entity #1

Entity #___

Entity #2

Entity #2

Entity #___

Entity #___Individual #2

Individual #___

ENTITY #2

NAME

ADDRESS

(List the required information for any additional entities on Attachment 2 at the end of this form.)

Street

Country

City

Phone number

Province/State

Website

2.


whistleblower(s)

FORM C

If NO, if you know, please indicate where the individual in A) above was employed at the time of the misconduct:

Individual #1 Entity name

Entity name

Entity name

Individual #2

Individual #___


1 2 3 4 5

3.


whistleblower(s)

FORM C



2 WHAT HAPPENED?PART

Illegal insider trading and/or tipping

Illegal distribution and/or unregistered trading

Fraud

Corporate disclosure and/or financial statements

From ____/__ (Year/Month) To ____/__ (Year/Month)

I don’t know

I don’t know

Other; please describe:

When did or when will each type of misconduct identified in A) aboveoccur? Check all that apply.

Describe the facts that lead you to believe that the above misconduct hasoccurred, is presently occurring, or is about to occur. Be as specific as possible.

The misconduct occurred in the past.

At what date ranges did it occur? Specify type of misconduct (from A.) above:

From ____/__ (Year/Month) I don’t know

The misconduct is currently ongoing.

At what date did it start? Specify type of misconduct (from A.) above:

The misconduct is about to occur sometime in the future. Specify type of misconduct (from A.) above:

I don’t know; Specify type of misconduct (from A.) above:

(Provide any additional information on the back of this form or on a separate sheet of paper and attach it to this form.)


1 2 3 4 5

What type of securities-related misconduct do you believe has occurred, is presently occurring, or will occur? Check all that apply.

4.


whistleblower(s)

FORM C



How did you learn about the above misconduct?

When did you learn about the above misconduct?

What do you believe is the magnitude of the misconduct? (For example, how much money is involved? How many people are being harmed?)

Year ____, Month __




2 3 4 5

.

5.


whistleblower(s)

FORM C



1


(If necessary, provide any additional information on a separate sheet of paper and attach it to this form.)


3 4 2 5

Do you currently have documents or materials in your possession or control,that you wish to provide to the OSC, to support the misconduct?

3 SUPPORTING DOCUMENTSPART

YES NO

If YES, if you are attaching files stored on a physical storage medium (such as a USB thumb drive) and/or physicaldocuments, please describe each document and provide details below.

Please do not reference or attach any documents that may reflect legal advice, that are communications with a lawyer for the purpose of obtaining legal advice or related working papers or that may otherwise be subject to solicitor-client privilege.

Document description How was it obtained? Is it likely to reveal your identity? If yes, please explain

Are there additional documents or materials available to support themisconduct which are not in your possession or control?

B

YES

1.

2.

3.

4.

5.

NO I DON’T KNOW

If YES, please describe the additional documents and the location of each document. Please also indicate if any ofthe additional documents are likely to reveal your identity.

Please do not reference any documents that may reflect legal advice, that are communications with a lawyer for the purpose of obtaining legal advice or related working papers or that may otherwise be subject to solicitor-client privilege.We do not expect you to obtain documents or other things that are not in your possession or control.

6.


whistleblower(s)

FORM C



1


4 2 5 3

Have you or the whistleblower(s) had any prior communication with the OSCregarding this matter?

A

Are you or the whistleblower(s) involved in legal proceedings regarding thismatter?

C

4 ABOUT THE WHISTLEBLOWER(S)PART


If YES, please specify:i) Person at the OSC (if known) that you dealt with: ii) Date of your initial communication (Year, Month, Day):

Have you or the whistleblower(s) had any communication with another securitiesregulator, self-regulatory organization (such as the Investment IndustryRegulatory Organization of Canada (IIROC), or the Mutual Fund DealersAssociation (MFDA)), government official, or a law enforcement agencyregarding this matter?

B

(If necessary, provide any additional information on a separate sheet of paper and attach it to this form.)



If YES, please specify:

If YES,

i) Organization(s):ii) Person at the organization (if known) that you dealt with: iii) Date of your initial communication (Year, Month, Day): iv) Action taken by that party (if any, if known):

i) What is your or that person’s involvement in the legal proceedings? For example, are you or that person a plaintiff, defendant or witness? ii) Describe the type and timing of the legal proceedings.

7.


whistleblower(s)

FORM C



1


4 2 5 3

D


If YES, please detail:

Did the whistleblower(s) obtain this information while conducting an inquiry or investigation into possible violations of law?

E

YES NO PREFER NOT TO ANSWER

If YES, please describe their involvement:

Were the whistleblower(s) involved in the misconduct?

8.


whistleblower(s)

FORM C

F Is there anything else you would like to tell us?



1


4 2 5 3

9.


whistleblower(s)

FORM C



LAWYER’S CONTACT INFORMATION GName of Law Firm Lawyer’s Name

Street

Daytime Phone

City Province/State, Country

Email

1


52 3 4

1

2

3

4

I, ____________, certify that I have read and agree to the above. ______________ _____________ (Print Name) (Signature) (Date)

As the lawyer representing the whistleblower, please agree to the above counsel certification.

5 COUNSEL CERTIFICATIONPART

I confirm that I have read OSC Policy 15-601 – Whistleblower Program; and explained it to my client, the whistleblower in this matter.

I confirm that I have verified the whistleblower’s identity by viewing valid government issued identification of the whistleblower.

I confirm that the whistleblower has provided me with a complete and signed Whistleblower Submission Form including a Whistleblower certification, the originals of which I retain in my records.

I have confirmed with the whistleblower that, to the best of their knowledge and belief, the information submitted is true and complete.

Please mail the Whistleblower Submission Form, and include supporting documents or materials, to the following address: Office of the Whistleblower - ConfidentialOntario Securities Commission22nd Floor20 Queen Street WestToronto, ON M5H 3S8

10.




whistleblower(s)

FORM C

1


Attachments

A2 3 4 5

INDIVIDUAL #3

NAME

ADDRESS

1. WHO ARE THE INDIVIDUALS INVOLVED IN THE MISCONDUCT?

Please provide details of additional individuals involved in the misconduct here.

ATTACHMENT

First Last

Street

Country

City

Phone number

Job position/Title

Province/State

Email

INDIVIDUAL #4

NAME

ADDRESS

First Last

Street

Country

City

Phone number

Job position/Title

Province/State

Email

INDIVIDUAL #5

NAME

ADDRESS

First Last

Street

Country

City

Phone number

Job position/Title

Province/State

Email

11.




whistleblower(s)

FORM C

1


Attachments

A2 3 4 5

2. WHO ARE THE ENTITIES INVOLVED IN THE MISCONDUCT? ATTACHMENT

12.




whistleblower(s)

FORM C

Please provide details of additional entities involved in the misconduct here.

1

ENTITY #3

NAME

ADDRESS Street

Country

City

Phone number

Province/State

Website

ENTITY #4

NAME

ADDRESS Street

Country

City

Phone number

Province/State

Website

ENTITY #5

NAME

ADDRESS Street

Country

City

Phone number

Province/State

Website

(Page left intentionally blank. Please provide any additional information here, as necessary.)

13.


whistleblower(s)

FORM C

whistleblower submission form form c · whistleblower submission form including a whistleblower...

Documents